Management of Muscle Relaxation With Rocuronium and Reversal With Neostigmine or Sugammadex Guided by Quantitative Neuromuscular Monitoring.

BACKGROUND: The optimal pharmacological reversal strategy for neuromuscular blockade remains undefined even in the setting of strong recommendations for quantitative neuromuscular monitoring by several national and international anesthesiology societies. We evaluated a protocol for managing rocuronium blockade and reversal, using quantitative monitoring to guide choice of reversal agent and to confirm full reversal before extubation. METHODS: We conducted a prospective cohort study and enrolled 200 patients scheduled for elective surgery involving the intraoperative use of rocuronium. Providers were asked to adhere to a protocol that was similar to local practice recommendations for neuromusculalr block reversal that had been used for >2 years; the protocol added quantitative monitoring that had not previously been routinely used at our institution. In this study, providers used electromyography-based quantitative monitoring. Pharmacological reversal was accomplished with neostigmine if the train-of-four (TOF) ratio was 0.40 to 0.89 and with sugammadex for deeper levels of blockade. The primary end point was the incidence of postoperative residual neuromuscular blockade (PRNB), defined as TOF ratio <0.9 at time of extubation. We further evaluated the difference in pharmacy costs had all patients been treated with sugammadex. RESULTS: A total of 189 patients completed the study: 66 patients (35%) were reversed with neostigmine, 90 patients (48%) with sugammadex, and 33 (17%) patients recovered spontaneously without pharmacological reversal. The overall incidence of residual paralysis was 0% (95% CI, 0-1.9). The total acquisition cost for all reversal drugs was United States dollar (USD) 11,358 (USD 60 per patient) while the cost would have been USD 19,312 (USD 103 per patient, 70% higher) if sugammadex had been used in all patients. CONCLUSIONS: A protocol that includes quantitative monitoring to guide reversal with neostigmine or sugammadex and to confirm TOF ratio ≥0.9 before extubation resulted in the complete prevention of PRNB. With current pricing of drugs, the selective use of sugammadex reduced the total cost of reversal drugs compared to the projected cost associated with routine use of sugammadex for all patients.

The Planetary Benefit of Suspending USMLE Step 2 CS: Estimating Carbon Emissions Associated with US Medical Students' Travel to Testing Centers.

Background: The discontinuation of the Step 2 Clinical Skills Exam (CS) by the United States Medical Licensing Examination (USMLE) eliminated the need for personal travel to testing centers. The carbon emissions associated with CS have not been previously quantified. Objective: To estimate the annual carbon emissions generated by travel to CS Testing Centers (CSTCs) and to explore differences across geographic regions. Methods: We conducted a cross-sectional, observational study by geocoding medical schools and CSTCs to calculate the distance between them. We obtained data from the 2017 matriculant databases of the Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM). The independent variable was the location as defined by USMLE geographic regions. The dependent variables were distance traveled to CSTCs and estimated carbon emissions in metric tons CO2 (mtCO2) calculated using three models. In model 1 all students used single occupancy vehicles; in model 2, all carpooled; and in model 3, half traveled by train and half by single occupancy vehicle. Results: Our analysis included 197 medical schools. The mean out-of-town travel distance was 280.67 miles (IQR: 97.49-383.42). The mtCO2 associated with travel was 2,807.46 for model 1; 3,135.55 for model 2; and 635.34 for model 3. The Western region traveled the farthest, while the Northeast traveled significantly less than other regions. Conclusion: The annual estimated carbon emissions from travel to CSTCs was approximately 3,000 mtCO2. Northeastern students traveled the shortest distances; the average US medical student expended 0.13 mtCO2. Medical leaders must consider the environmental impact of medical curricula and pursue accordant reforms.

Globalization of Plastic and Reconstructive Surgery: A Continent, Country, and State-Level Analysis of Publications.

Over the past decade, there has been a worldwide increase in plastic and reconstructive surgery research as well as increased interest in global collaboration. However, little is known about who is contributing to this global expansion or the trends of individual countries. The aim of our study was to analyze the output of Plastic and Reconstructive Surgery (PRS) over a decade to elucidate trends in the plastic surgery field. METHODS: The country of origin for all first authors of articles published by PRS from 2010 to 2019 were determined and date extracted using PubMed2XL. The change in frequency of publications over the decade by country, continental contributions, as well as state-level analysis within the United States were analyzed. RESULTS: From 2010 to 2019, there were a total number of 8680 publications with an increase in total articles from 747 to 1049 per year. 54 countries contributed over the decade, with the United States producing the most followed by Italy, China, Canada, and the UK. The top producing states were Texas, New York, California, Massachusetts, and Pennsylvania. CONCLUSIONS: The last decade (2010-2019) saw a large international increase in research, not only with the total number of publications, but also in the diversity of originating country. Our work shows a shift away from a US-focused journal to incorporate more work from our international colleagues, as research is conducted in centers across the globe.